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 Table of Contents  
PHOTO ESSAY
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 441-442

The clue lies in the details


1 Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Aditya Birla Sankara Nethralaya, Kolkata (A Unit of Medical Research Foundation, Chennai), West Bengal, India
2 Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India

Date of Submission02-Sep-2020
Date of Acceptance23-Feb-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Md Shahid Alam
Aditya Birla Sankara Nethralaya, Kolkata - 700 099, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2851_20

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  Abstract 


Keywords: CT, Cysticercosis, MRI, orbital, scolex


How to cite this article:
Alam MS, Banerjee P. The clue lies in the details. Indian J Ophthalmol Case Rep 2021;1:441-2

How to cite this URL:
Alam MS, Banerjee P. The clue lies in the details. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 26];1:441-2. Available from: https://www.ijoreports.in/text.asp?2021/1/3/441/320018



A 33-year-old man presented with a history of painless prominence of the right eye for the past 6 months. On examination a proptosis of 4 mm was present in the right eye [Figure 1]a, with limitation of abduction. Rest of the ophthalmic examinations was unremarkable in both the eyes. Patient already had a computerized tomography (CT) scan done which showed a well-defined mass in the medial orbit and was reported as a cavernous hemangioma [Figure 1]b, the axial cuts however showed an irregular mass inseparable from the medial rectus with a central hypodensity [Figure 1]c. He was referred for a medial orbitotomy and excision of the mass lesion. However the clinical picture of abduction limitation and the mass being in separable from the medial rectus and the central hpodense area raised sufficient doubts for it to be a cavernous hemangioma and a magnetic resonance imaging (MRI) of the orbit was advised, which revealed edematous medial rectus with a cystic mass having a T2 hyperintense lesion within it [Figure 1]d and [Figure 1]e, suggestive of medial rectus myo-cysticercosis. The patient was started on 4 weeks course of oral albendazole therapy (15 mg/kg/day) along with tapering oral steroid (1 mg/kg).
Figure 1: (a) Primary gaze photograph showing prominence of right eye. (b) CT scan coronal cut showing a well defined mass lesion in the right medial orbit. (c) CT scan axial cut showing a mildly irregular mass in the medial orbit inseparable from the medial rectus and a central hypodensity. (d and e) MRI T2 weighted sequence (Coronal and axial cuts at same level) showing a hypointense cyst arising from the medial rectus muscle with a hyperintense scolex within it (yellow arrow)

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  Discussion Top


Orbital myo-cysticercosis commonly presents with ocular motility restriction, diplopia, proptosis, ptosis, and strabismus.[1],[2],[3] CT and MRI, along with Ultrasonography (USG-B scan) of the orbit are the imaging modalities widely used for the diagnosis of orbital cysticercosis. CT scan reveals a round hypodense area with an eccentric hyperdense dot indicating the scolex. On MRI the cyst appears as a hypointense area with a hyperintense scolex on T2-weighted sequences.[4] MRI is more sensitive than CT and is the investigation of choice.[4]

In the present case, though the lesion appeared as a well-defined mass on CT scan suggesting a cavernous hemangioma, the very fact that the lesion appeared to arise from the medial rectus with the muscle not being visualized separately and the mixed rather than uniform density within the mass raised sufficient doubts to consider an alternate diagnosis and ordering an MRI. The case highlights the fact of examining the scan plates closely by the oculoplastic surgeons themselves and discussing the case with the radiologist whenever in doubt. One should not hesitate in ordering an MRI in cases where CT is not conclusive or doubtful and vice-versa, depending upon the nature of the lesion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Salim S, Alam MS, Backiavathy V, Raichura ND, Mukherjee B. Orbital cysticercosis: Clinical features and management outcomes. Orbit 2020;1-7.doi: 10.1080/01676830.2020.1833942.  Back to cited text no. 1
    
2.
Rath S, Honavar SG, Naik M, Anand R, Agarwal B, Krishnaiah S, et al. Orbital cysticercosis: Clinical manifestation, diagnosis, management and outcome. Ophthalmology 2010;117:600-5.  Back to cited text no. 2
    
3.
Ganesh SK, Priyanka. Analysis of clinical profile, investigation, and management of ocular cysticercosis seen at a tertiary referral centre. Ocul Immunol Inflamm 2018;26:550-7.  Back to cited text no. 3
    
4.
Tripathy SK, Sen RK, Akkina N, Hampannavar A, Tahasildar N, Limaye R. Role of ultrasonography and magnetic resonance imaging in the diagnosis of intramuscular cysticercosis. Skeletal Radiol 2012;41:1061-6.  Back to cited text no. 4
    


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